Morgan Stephen, Mant David
Department of Primary Medical Care, University of Southampton, Aldermoor Health Centre.
Br J Gen Pract. 2002 May;52(478):373-4, 377-80.
Atrial fibrillation is a common and treatable cause of stroke that often remains unrecognised. Screening has been suggested but there is very little evidence concerning the uptake of screening in the elderly population at risk, nor of the optimal method of screening in a general practice setting
To compare the uptake and effectiveness of two methods of screening for atrial fibrillation in general practice--systematic nurse-led screening and prompted opportunistic case finding.
Randomised controlled trial.
Patients aged 65 to 100 years (n = 3,001) from four general practices within the MRC general practice framework.
Each of the four study practices were selected from one quartile, after ranking all framework practices according to the small area standardised mortality ratio of the geographical area served. Patients were randomised either to nurse-led screening or to prompted opportunistic casefinding. The proportion of patients assessed and the proportion found to have atrial fibrillation were compared. The sensitivity and specificity of clinical assessment of pulse are also reported.
Substantially more patients had their pulse assessed through systematic screening by invitation (1,099/1,499 [73%]) than through opportunistic case finding (439/1,502 [29%], difference = 44%, 95% confidence interval [CI] = 41% to 47%). Atrial fibrillation was detected in 67 (4.5%) and 19 (1.3%) patients respectively (difference = 3.2%, 95% CI= 2.0 to 4.4). Invitation to nurse-led screening achieved significantly higher assessment rates than case finding in all practices; however, the proportion of patients assessed in the case-finding arm varied markedly between practices (range = 8% to 52%). The number needed to screen to identify one additional patient with atrial fibrillation was 31 (95% CI = 23 to 50). The proportion of screened patients with atrial fibrillation receiving anticoagulation treatment was 25%, although in the majority (53/65 [82%]) atrial fibrillation had been previously recorded somewhere on their medical record. If the nurse used any irregularity of the pulse as the screening criterion, the sensitivity of screening was 91% and the specificity was 74%; sensitivity fell to 54% but specificity increased to 98% if the criterion used was continuous irregularity.
Nurse-led screening for atrial fibrillation in UK general practice is both feasible and effective and will identify a substantial number of patients who could benefit from antithrombotic therapy. Although the majority of patients detected at first screening could be identified by careful scrutiny of medical records, review of record summaries was insufficient in the practices involved in this study and screening may be a more cost-effective option.
心房颤动是一种常见且可治疗的中风病因，但常常未被识别。有人提议进行筛查，但关于高危老年人群筛查的接受情况以及在全科医疗环境中最佳筛查方法的证据非常少。
比较全科医疗中两种心房颤动筛查方法的接受情况和有效性——由护士主导的系统筛查和机会性病例发现。
随机对照试验。
来自医学研究委员会全科医疗框架内四个全科医疗诊所的65至100岁患者（n = 3001）。
在根据所服务地理区域的小面积标准化死亡率对所有框架诊所进行排名后，从四个四分位数中各选一个研究诊所。患者被随机分配到由护士主导的筛查组或机会性病例发现组。比较接受评估的患者比例和被发现患有心房颤动的患者比例。还报告了脉搏临床评估的敏感性和特异性。
通过邀请进行系统筛查的方式评估脉搏的患者（1099/1499 [73%]）比通过机会性病例发现的方式（439/1502 [29%]，差异 = 44%，95%置信区间[CI] = 41%至47%）多得多。分别在67例（4.5%）和19例（1.3%）患者中检测到心房颤动（差异 = 3.2%，95%CI = 2.0至4.4）。在所有诊所中，邀请进行由护士主导的筛查的评估率显著高于病例发现；然而，病例发现组中接受评估的患者比例在不同诊所之间差异很大（范围 = 8%至52%）。识别出另外一名心房颤动患者所需的筛查人数为31人（95%CI = 23至50）。接受抗凝治疗的筛查出的心房颤动患者比例为25%，尽管大多数（53/65 [82%]）患者的病历中此前已在某处记录有心房颤动。如果护士将任何脉搏不规则作为筛查标准，筛查的敏感性为91%，特异性为74%；如果使用的标准是持续性不规则，则敏感性降至54%，但特异性升至98%。
在英国全科医疗中，由护士主导的心房颤动筛查既可行又有效，将识别出大量可从抗血栓治疗中获益的患者。尽管首次筛查时检测出的大多数患者可通过仔细查阅病历识别出来，但在本研究涉及的诊所中，病历摘要审查并不充分，筛查可能是一种更具成本效益的选择。
